Assessing fever in children

GPs must distinguish benign and life-threatening conditions rapidly.

Feverish illness in young children usually indicates an underlying infection and can be extremely worrying for parents and carers. Between 20 and 40% of young children will have a feverish illness each year.1

Feverish illness is probably the most common reason for a child to be taken to the GP and is the second most common reason for a child being admitted to hospital. It is important that this condition is managed appropriately as infections are still the leading cause of death in children under the age of five years.

The majority of cases presenting in primary care are due to a self-limiting viral infection. However, it is important to be able to quickly distinguish benign conditions from life-threatening.2 Missed bacterial infections in children can result in meningitis, sepsis, and death; therefore, early and accurate identification of serious bacterial infections is critical.3

Following the widespread use of immunisations against Streptococcus pneumoniae and Haemophilus influenzae type b, the epidemiology of bacterial infections causing fever has changed over recent years.4

Assessment of fever

Children over four weeks of age should have their temperature measured by electronic or chemical dot thermometers in the axilla or by an infra-red tympanic thermometer. Forehead clinical thermometers are no longer recommended.

Current NICE guidelines state that children with feverish illness should be assessed for the presence or absence of symptoms and signs that can be used to predict the risk of serious illness using the traffic light system. Children with any of the symptoms or signs in the red column should be recognised as being at high risk.1

Table 1. Traffic light system for identifying risk of serious illness1

The following should be clearly recorded:

  • Temperature
  • Heart rate
  • Respiratory rate/
  • Capillary refill time

Although children under the age of three months with a temperature of at least 38°C are in a high-risk group for serious illness, in children over six months the severity of the temperature alone is not enough to identify those with a serious illness.

The Advanced Paediatric Life Support (APLS) criteria should be used to define tachycardia as follows:5

< 12 months >160
12-24 months  >150
2-5 years >140

Clinical assessment

Any life-threatening features (e.g., airway compromise or reduced level of consciousness) should be identified promptly and the child admitted immediately for emergency medical care.

A thorough clinical examination should be undertaken to try to determine the underlying cause of the fever.

The following symptoms and signs suggest meningococcal disease in a child with a fever:

  • Ill-looking child
  • Purpura present more than 2mm in diameter
  • Capillary refill time ≥ 3 seconds
  • Neck stiffness

Signs and symptoms of bacterial meningitis may include:

  • Neck stiffness
  • Bulging fontanelle
  • Decreased level of consciousness
  • Convulsive status epilepticus

Management of children with a fever

Paracetamol or ibuprofen can be given; however, they do not prevent febrile convulsions. It is no longer recommended that these medications should be given at the same time, they can be alternated if the distress persists or recurs though.1 There is some evidence that both alternating and combined antipyretic therapy may be more effective at reducing temperatures than monotherapy alone. However, the evidence for improvements in measures of child discomfort remains inconclusive.6

The actual management of a child with a fever should be according to their individual level of risk as determined by the traffic light system:

  • Children with any "red" features but who are not considered to have an immediately life-threatening illness should be referred urgently to the care of a paediatric specialist.
  • In children with any "amber" features present but where no diagnosis has been made, parents or carers should be given a safety net or be referred to specialist paediatric care for further assessment.
  • This safety net should be at least one of the following:
    • Providing the parent or carer with verbal and/or written information on warning symptoms and how further healthcare can be accessed
    • Arranging further follow-up at a specified time and place
    • Liaising with other healthcare professional to ensure direct access for the child if further assessment is required
  • Children with only "green" features can be cared for at home with appropriate advice for parents and carers, including advice on when to seek further attention from the healthcare services.

Antibiotics should not be given routinely. They should be given appropriately if an underlying cause of infection is determined, for example a urinary or chest infection. Children with symptoms and signs suggestive of pneumonia should be treated appropriately and do not need a chest X-ray routinely.7

Parenteral antibiotics should be given without delay to those children with suspected meningococcal disease (either benzylpenicillin or a third-generation cephalosporin).

  • Dr Newson is a GP in the West Midlands

  • Feverish illness in children is very common in primary and secondary care
  • Serious bacterial infections need to be diagnosed and managed promptly
  • The traffic light system should be used to assess children with a fever
  • Children with any symptoms or signs in the red column of the traffic light system need urgent admission
  • Antipyretics do not prevent febrile convulsions
  • Antibiotics should not be given without knowing the cause of fever
  • Children with any symptoms or signs indicative of meningococcal disease need urgent parenteral antibiotics

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  1. NICE. Feverish illness in children: assessment and initial management in children younger than five years. (Clinical guideline CG160.) 2013
  2. Wing R, Dor MR, McQuilkin PA. Fever in the pediatric patient. Emerg Med Clin North Am 2013; 31(4): 1073-96.
  3. Arora R, Mahajan P. Evaluation of child with fever without source: review of literature and update. Pediatr Clin North Am 2013; 60(5): 1049-62.
  4. Hamilton JL, John SP. Evaluation of fever in infants and young children. Am Fam Physician 2013; 87(4): 254-60.
  5. Advanced Life Support Group (2004) Advanced paediatric life support: the practical approach (4th edn). Wiley-Blackwell
  6. Wong T, Stang AS, Ganshorn H, et al. Combined and alternating paracetamol and ibuprofen therapy for febrile children. Evid Based Child Health 2014; 9(3): 675-729.
  7. Harris M, Clark J, Coote N, et al; British Thoracic Society Standards of Care Committee. British Thoracic Society guidelines for the management of community acquired pneumonia in children: update 2011. Thorax 2011; 66 Suppl 2:ii1-23.

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